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MENTAL HEALTH & Substance Abuse Concurrent Disorders SWRK 2083 Keith Cameron, M.A., M.B.A.

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Presentation on theme: "MENTAL HEALTH & Substance Abuse Concurrent Disorders SWRK 2083 Keith Cameron, M.A., M.B.A."— Presentation transcript:

1 MENTAL HEALTH & Substance Abuse Concurrent Disorders SWRK 2083 Keith Cameron, M.A., M.B.A.

2 Agenda Week 1 Introduction Introduction Course Outline & Administrative Issues Course Outline & Administrative Issues Introduction to Concurrent Disorders Introduction to Concurrent Disorders Definition of Key Term Definition of Key Term Clinical Complexity Clinical Complexity Class practical exercises Class practical exercises

3 Introduction Keith Cameron, M.A., M.B.A. Keith Cameron, M.A., M.B.A. Contact Information Contact Information No contact at the College No contact at the College Web site: Web site: It is your responsibility to access the web-site for power point presentations It is your responsibility to access the web-site for power point presentations They will be posted by the end of the day on the Tuesday prior to class I will not be bringing copies to class Other information may be posted that is FYI only but may be beneficial in assignments or the test

4 Course Outline EVALUATION SYSTEM: Week 3 – Multiple Choice Quiz (20%) Week 3 – Multiple Choice Quiz (20%) Open book and work in pairs Open book and work in pairs Week 4 – Small Group Work – 3 maximum (30%) Week 4 – Small Group Work – 3 maximum (30%) Week 7 – Final Multiple Choice (40%) Week 7 – Final Multiple Choice (40%) Attendance (10%) Attendance (10%) Those that have been granted job status will be prorated out of 90 Those that have been granted job status will be prorated out of 90 Religious holidays. It is the student’s responsibility to discuss this issue with your professor at least one week before the holiday. Religious holidays. It is the student’s responsibility to discuss this issue with your professor at least one week before the holiday. Students registered with Disability Services are required to supply confirming documentation to the professor and inform him/her of any plans to write tests in private Students registered with Disability Services are required to supply confirming documentation to the professor and inform him/her of any plans to write tests in private It is your responsibility to read and understand the course outline. Ask if you are not sure It is your responsibility to read and understand the course outline. Ask if you are not sure

5 Course Outline – Cont’d ASSIGNMENT POLICY: PLS. READ CAREFULLY! Group work is submitted at the end of class. Group work is submitted at the end of class. If 1 assignment is missed If 1 assignment is missed You must contact the professor on the day of the assignment at the latest ( no documentation is required) You must contact the professor on the day of the assignment at the latest ( no documentation is required) by by If you have contacted the professor, only then will be eligible for a make up after the final test on week 7 If you have contacted the professor, only then will be eligible for a make up after the final test on week 7 If you miss a second assignment: If you miss a second assignment: You must contact the professor on the day of the assignment and must provide documentation within one week to access any accommodation You must contact the professor on the day of the assignment and must provide documentation within one week to access any accommodation Groups will consist of 3 members Groups will consist of 3 members Each member is to participate in written response Each member is to participate in written response Members are expected to participate equally and remain until the work is completed. Members are expected to participate equally and remain until the work is completed. Groups who sign in a missing group participant will be liable for sanctions as a whole ( i.e. 0 on that assignment) Groups who sign in a missing group participant will be liable for sanctions as a whole ( i.e. 0 on that assignment) To view George Brown College policies go to To view George Brown College policies go to

6 General Comments Please ask questions Please ask questions If you don’t know others also don’t know If you don’t know others also don’t know It is your right to have explanations and clarifications It is your right to have explanations and clarifications Very often there are not right and wrong answers Very often there are not right and wrong answers Because I say it doesn’t mean it is right Because I say it doesn’t mean it is right I would request that any backbench talking be done outside the class I would request that any backbench talking be done outside the class This is disturbing to me and the rest of the class This is disturbing to me and the rest of the class I will not talk above other people I will not talk above other people Turn cell phones off Turn cell phones off If there is an emergency call awaiting let me know If there is an emergency call awaiting let me know Keep assignments including scantrons in case of a discrepancy in marks. No marks will changed without this back-up support Keep assignments including scantrons in case of a discrepancy in marks. No marks will changed without this back-up support

7 A Few Pointers Readings Readings Reading package available at College Reading package available at College Note that when you first open “Health Canada” document it is in Roman numerals – keep scrolling down until you get to the page numbers Note that when you first open “Health Canada” document it is in Roman numerals – keep scrolling down until you get to the page numbers Note page number on the document will not correspond to the scroll down pages on the left Note page number on the document will not correspond to the scroll down pages on the left

8 Mental Illness S. Abuse: How we define them Context of Behaviour Context of Behaviour Social Deviance Social Deviance Persistence of maladaptive behaviours Persistence of maladaptive behaviours Subjective distress Subjective distress Severity Severity Impact on functioning Impact on functioning Tolerance Tolerance Withdrawal symptoms Withdrawal symptoms Need more, same effect Need more, same effect Persistent drive for substance, or failure to cut back Persistent drive for substance, or failure to cut back Time spent getting it Time spent getting it Reduce social/work activities Reduce social/work activities Use despite health/social problems Use despite health/social problems

9 Some Themes for the Course Complexity Complexity Numerous MH disorders combined with different disorders Numerous MH disorders combined with different disorders Age/demographics Age/demographics Assessing Concurrent Disorders (CD) Assessing Concurrent Disorders (CD) What came first? What came first? What do we treat? What do we treat? Treatment Treatment What came first? What came first? What do we treat first What do we treat first Causes of CD Causes of CD What went wrong in childhood? What went wrong in childhood? Focus Focus Mood + Alcohol Mood + Alcohol Anxiety + Alcohol Anxiety + Alcohol Psychosis & Cannabis Psychosis & Cannabis

10 Definition What is your understanding of the term Concurrent Disorders What is your understanding of the term Concurrent Disorders What it is not! What it is not!

11 What do We Mean by Concurrent Disorders? At least one mental health disorder as defined by DSM-IV At least one mental health disorder as defined by DSM-IV Plus substance abuse or dependence as defined by DSM-IV Plus substance abuse or dependence as defined by DSM-IV Multi combinations and variations, including multi-morbidity Multi combinations and variations, including multi-morbidity Across drugs Across drugs Across mental disorders Across mental disorders Demographics/cultural groups Demographics/cultural groups

12 Abuse vs. Dependence Substance abuse is a pattern of drug, alcohol or other substance use that creates many adverse results from its continual use. The characteristics of abuse are a failure to carry out obligations at home or work, continual use under circumstances that present a hazard (such as driving a car), and legal problems such as arrests. Use of the drug is persistent despite personal problems caused by the effects of the substance on self or others.personal problems Substance dependence has been defined medically as a group of behavioural and physiological symptoms that indicate the continual, compulsive use of a substance in self-administered doses despite the problems related to the use of this substance. Sometimes increased amounts are needed to achieve the desired effect or level of intoxication. Consequently the patient's tolerance for the drug increases. Withdrawal is a physiological and psychological change that occurs when the body's concentration of the substance declines in a person who has been a heavy user.

13 Definition in Canada (Similar in the USA) “A combination of mental/emotional/psychiatric problems with the abuse of alcohol and/or other psychoactive drugs…any combination of mental health and substance use disorders, as defined in DSM IV.” (Cooper & Calderwood in readings) “A combination of mental/emotional/psychiatric problems with the abuse of alcohol and/or other psychoactive drugs…any combination of mental health and substance use disorders, as defined in DSM IV.” (Cooper & Calderwood in readings) In definition, the DSM–IV is used as the tool for diagnosis (Axis 1 & 2) In definition, the DSM–IV is used as the tool for diagnosis (Axis 1 & 2)

14 Some Terms CAMI: chemically abusing – mentally ill CAMI: chemically abusing – mentally ill MICA: Mentally ill – chemically abusing MICA: Mentally ill – chemically abusing SAMI: Substance abusing – mentally ill SAMI: Substance abusing – mentally ill Co-occurring (the US) Co-occurring (the US) ‘Double-jeopardy’ ‘Double-jeopardy’

15 What is a Dual Disorder??

16 Not Dual Disorders People with MH + Substance abuse may have more than 2 disorders People with MH + Substance abuse may have more than 2 disorders Dual Disorders Dual Disorders In Canada, refers to Developmental Delay & a Mental Health issue In Canada, refers to Developmental Delay & a Mental Health issue Concurrent Disorders Concurrent Disorders In Canada, captures complexity of substance abuse with mh In Canada, captures complexity of substance abuse with mh

17 Prevalence Data From Journal of American Medical Association Large overlap: between substance use and mental health disorders Large overlap: between substance use and mental health disorders Most clients who actually seek treatment have a concurrent disorder Most clients who actually seek treatment have a concurrent disorder

18 Some Stats 50% of seriously mentally ill affected by substance abuse 50% of seriously mentally ill affected by substance abuse 90% of mentally ill smoke heavily 90% of mentally ill smoke heavily 77% of those treated for alcohol-related disorders have experienced at least one other psychiatric disorder in their lifetimes. 77% of those treated for alcohol-related disorders have experienced at least one other psychiatric disorder in their lifetimes.

19 Some Specifics Schizophrenia Schizophrenia 47% also have a substance abuse disorder, which is 4x the risk of the general population 47% also have a substance abuse disorder, which is 4x the risk of the general population Bipolar Disorder Bipolar Disorder 61% also had a substance abuse disorder which is 5x the risk of the general population 61% also had a substance abuse disorder which is 5x the risk of the general population

20 Specific Risks Compared to general population the lifetime risk for developing alcohol dependence is: Compared to general population the lifetime risk for developing alcohol dependence is: 21 times higher for Antisocial Personality 21 times higher for Antisocial Personality 6 timers higher for those with Mania 6 timers higher for those with Mania 4x higher for those with schizophrenia 4x higher for those with schizophrenia 2x higher for those with panic disorder, major depression, & OCD 2x higher for those with panic disorder, major depression, & OCD

21 Most Common Combinations Specifically Mood Disorder plus Alcohol Mood Disorder plus Alcohol Anxiety Disorder plus Alcohol Anxiety Disorder plus Alcohol

22 Five Most Common Groupings (Health Canada) 1. Substance Use + Mood & Anxiety Disorders 2. Substance Use + Severe & Persistent MH 3. Substance Use & Personality Disorders 4. Substance Use + Eating Disorders 5. Other Substance Use & MH

23 Key to Practitioners Only a minority of substance abusers and those with mental health problems reach out for help….but… Only a minority of substance abusers and those with mental health problems reach out for help….but… “…those in the general population with concurrent disorders present the highest probability of seeking treatment.” Kessler “…those in the general population with concurrent disorders present the highest probability of seeking treatment.” Kessler

24 Key---- US Study: Respondents with alcohol use disorders were five times as likely to see help when they also had a mental health problem. US Study: Respondents with alcohol use disorders were five times as likely to see help when they also had a mental health problem. “Those who seek help are the most severe cases in the general population…and are more often readmitted to treatment.” “Those who seek help are the most severe cases in the general population…and are more often readmitted to treatment.”

25 “Intersectionality:” ‘The experience of living with multiple stigmatized identities, facing multiple layers of discrimination.’ Article: “Multiple Identities, Multiple Barriers”: U. Chandraseskera

26 Complexity = Multiple Identities Each with its own unique issues… Each with its own unique issues… S Abuse M Illness LGBTQ People of Color Class New Canadian Gender

27 Consequences of Having a Concurrent Disorder Statistically, clients have a greater propensity for violence, medication non-compliance, and failure to respond to treatment…compared with clients with substance abuse only or mental illness only “These consumers are in and out of hospitals and treatment programs without lasting success.” (NAMI) “These consumers are in and out of hospitals and treatment programs without lasting success.” (NAMI) Treatment takes longer to work Treatment takes longer to work

28 Consequences --- ‘Downward Drift’: ‘Downward Drift’: Mental illness lands clients in poor housing, in neighborhoods where drug use prevails…inability to form social relationships, isolation can lead to joining the drug sub-culture Mental illness lands clients in poor housing, in neighborhoods where drug use prevails…inability to form social relationships, isolation can lead to joining the drug sub-culture

29 Consequences --- Leads to homelessness or jail: Leads to homelessness or jail: Half of the mentally ill homeless have substance abuse problems Half of the mentally ill homeless have substance abuse problems 31% a concurrent disorder 31% a concurrent disorder 16% of prison inmates have concurrent disorders 16% of prison inmates have concurrent disorders Leads to overall poorer physical health and greater chance of relapse Leads to overall poorer physical health and greater chance of relapse “these consumers are in and out of hospital and treatment programs without lasting success.” (Nami)

30 Services lack integration “Often only one of the disorders is identified. If both are recognized, the individual may bounce back and forth between services, or be refused service by one of them….Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders.” (NAMI) “Often only one of the disorders is identified. If both are recognized, the individual may bounce back and forth between services, or be refused service by one of them….Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders.” (NAMI)

31 Why CD Clients Quit Treatment Enter treatment in crisis or chronic state Enter treatment in crisis or chronic state Therapeutic alliance tougher to establish Therapeutic alliance tougher to establish Treatment streams not integrated (one disorder recognized) Treatment streams not integrated (one disorder recognized) Clients need longer-term treatment that many agencies do not offer Clients need longer-term treatment that many agencies do not offer Pattern of failed relationships, abuse: attachment issues Pattern of failed relationships, abuse: attachment issues

32 Double Stigma Is it better to be drug user or a mental health consumer? Is it better to be drug user or a mental health consumer? Mental Health Mental Health Becoming less stigmatized Becoming less stigmatized More education More education Better outcomes Better outcomes Addictions Addictions Still seen as a moral failure Still seen as a moral failure Judged more harshly Judged more harshly

33 Internalized Stigma Addiction: harsh judgment by our culture creates more durable internal stigma Addiction: harsh judgment by our culture creates more durable internal stigma Beliefs: I’m a loser, I’m a bad person, I don’t deserve help, I don’t deserve love Beliefs: I’m a loser, I’m a bad person, I don’t deserve help, I don’t deserve love

34 1+1 = more than 2 Substances make MH problems worse Substances make MH problems worse Substances mimic or hide MH problems Substances mimic or hide MH problems Substances used to relieve MH symptoms Substances used to relieve MH symptoms (Self-medication) (Self-medication) Substances can make MH meds less effective Substances can make MH meds less effective Substances can lead to clients forgetting to take MH meds Substances can lead to clients forgetting to take MH meds Relapse with one triggers symptoms of other problem Relapse with one triggers symptoms of other problem

35 Consequences for Treatment Overall, poor outcomes: chronic course Overall, poor outcomes: chronic course Poor physical health Poor physical health High relapse rates High relapse rates ‘Recidivism’ ‘Recidivism’ So: clients more likely to seek help, and also to quit help So: clients more likely to seek help, and also to quit help

36 Treatment “Co-existing mental disorders increase the probability of abandoning treatment prematurely.” “Co-existing mental disorders increase the probability of abandoning treatment prematurely.” WHY? WHY?

37 How Many Concurrent Combinations Are There?

38 Bio-Psycho Social Model Review A framework that incorporates the A framework that incorporates the NATURE vs. NURTURE controversy Examines the positive strengths of the consumer Examines the positive strengths of the consumer Recognizes the biological predisposition of mental illnesses & addictions Recognizes the biological predisposition of mental illnesses & addictions Recognizes the negative and positive elements in the environment Recognizes the negative and positive elements in the environment Organizes information in a way that can be communicated and include the consumer in decision making Organizes information in a way that can be communicated and include the consumer in decision making Recognizes the importance of the consumer in the treatment process Recognizes the importance of the consumer in the treatment process

39 Group Assignment As a group list your experience the last time you drank a lot of alcohol? As a group list your experience the last time you drank a lot of alcohol? Biological/Psychological/Social-Spiritual + Behavioural Biological/Psychological/Social-Spiritual + Behavioural BiologicalPsychologicalSocialBehavioural

40 List Features of Depression Consider such things as thinking, judgment, inherited vulnerability, depressed CNS, memory, social functioning, mood BiologicalPsychologicalSocialBehavioural

41 Alcohol Abuse vs. Depression How do we distinguish depression and alcohol abuse? How do we distinguish depression and alcohol abuse? Does alcohol abuse mask depression? Does alcohol abuse mask depression? Which came first? Which came first? Does one cause the other? Does one cause the other? Are they both hereditary or environmental? Are they both hereditary or environmental? Common pathway Common pathway Assessment is challenging Assessment is challenging

42 Add Other Factors That May Affect Assessment and Treatment


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